Record review and interviews revealed that R1 was a high fall risk and had a history of witnessed and unwitnessed falls. Staff interviews and review of R1’s Resident Assessment dated January 24, 2021, revealed that R1 required a status check four times each shift, not including meals, medications service, or when R1 called for assistance. R1 required a one-person total assist or wheelchair escort to and from activities, meals, etc. Record review and staff and outside source interviews revealed that R1 had one witnessed fall and two unwitnessed falls between January 19, 2021, to February 20, 2021, while residing in the Assisted Living (AL) unit of the facility. R1 was moved to the Memory Care (MC) unit of the facility on February 21, 2021, at the request of the facility staff and approval of R1’s representative due to the increase of R1’s falls.

R1 suffered four additional falls while living in the MC unit. Record review revealed R1 had an unwitnessed fall on March 27, 2021, and April 19, 2021. As a result of these falls, the facility staff assessed the resident and observed minor bruising and R1 had no complaints of pain. Interviews with staff and record review revealed on May 11, 2021, R1 suffered two unwitnessed falls. The first fall occurred at 8:00 PM, R1 was assessed by the facility nurse and had no complaints of pain and was able to flex all extremities within normal range. The second fall occurred between 9:00 PM to 10:00 PM, and R1 sustained a visible head wound. The facility staff immediately applied first aid and called emergency services to transport R1 to the hospital for an evaluation.

[Continued on LIC9099-C]

Review of R1’s medical records revealed that on May 12, 2021, the emergency department that discharged R1 to the hospital addressed R1’s representative agreeing to non-operative management of the fractures due to R1’s diagnoses and age. The medical records also addressed the emergency department’s recommendation of a needed placement to a skilled nursing facility upon R1’s discharge from the hospital. Interviews with internal and external sources revealed that the parties involved were aware that R1’s condition was not suitable for a memory care facility but rather required a skilled nursing facility. Interviews also revealed that the parties involved were aware that R1 could return to the facility post-discharge from a skilled nursing facility. Therefore, the allegation that R1 was unlawfully evicted is not supported as record review and interviews revealed that R1’s condition was not suitable for the memory care facility due to the higher level of care required.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the investigation did not yield the preponderance of the evidence to conclude neglect/lack of supervision resulted in resident’s fall and resident sustaining fractures, licensee not seeking timely medical care, and unlawful eviction has not been met. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.